Long-term outcomes and quality of life in critically ill patients with hematological or solid malignancies: a single center study.

PURPOSE: Data concerning long-term outcomes and quality of life (QOL) in critically ill cancer patients are scarce. The aims of this study were to assess long-term outcomes and QOL in critically ill patients with hematological (HM) or solid malignancies (SM) 3 months and 1 year after intensive care unit (ICU) discharge, to compare these with QOL before ICU admission, and to identify prognostic indicators of long-term QOL. METHODS: During a 1 year prospective observational cohort analysis, consecutive patients with HM or SM admitted to the medical or surgical ICU of a university hospital were screened for inclusion. Cancer data, demographics, co-morbidity, severity of illness, organ failures, and outcomes were collected. The QOL before ICU admission, 3 months, and 1 year after ICU discharge was assessed using standardized questionnaires (EuroQoL-5D, Medical Outcomes Study 36-item Short Form Health Survey). Statistical significance was attained at P < 0.05. RESULTS: There were 483 patients (85 HM, 398 SM) (64% men) with a median age of 62 years included. Mortality rates of HM compared to SM were, respectively: hospital (34 vs. 13%), 3 months (42 vs. 17%), and 1 year (66 vs. 36%) (P < 0.001). QOL declined at 3 months, but improved at 1 year although it remained under baseline QOL, particularly in HM. Older age (P = 0.007), severe comorbidity (P = 0.035), and HM (P = 0.041) were independently associated with poorer QOL at 1 year. CONCLUSIONS: Long-term outcomes and QOL were poor, particularly in HM. Long-term expectations should play a larger role during multidisciplinary triage decisions upon referral to the ICU.

Different responses to preoperative chemotherapy for invasive lobular and invasive ductal breast carcinoma.

AIM: Preoperative chemotherapy (PCT) is used in primary breast cancer, to facilitate breast conservative surgery (BCS). Clinical and pathologic responses are important prognostic parameters. Biologic markers are needed to individualize treatment. PATIENTS AND METHODS: One hundred and thirty-five patients with breast carcinoma were treated with PCT, followed by surgery and adjuvant therapy. Clinical response and pathological complete response (pCR), biological markers and type of surgery were compared between invasive ductal (IDC) and invasive lobular carcinoma (ILC). RESULTS: Overall response (OR) for IDC was 75% compared to 50% for ILC (P=0.0151). Pathological CR was 15% for IDC and 0% for ILC (P=0.0066). Fifty-six percent of the responding patients had BCS, in contrast with 16% of the non-responders. BCS was performed in 50% of patients with IDC, in 38% of the patients with ILC. Salvage surgery was more necessary in ILC (19%) compared to IDC (4%) (P=0.0068). Patients with ILC were more frequently ER-positive and HER-2 negative than patients with IDC. CONCLUSIONS: Clinical and pathological responses are lower in ILC compared to IDC. After PCT, patients with large ILC should preferably be offered mastectomy with immediate breast reconstruction. However, PCT still remains valuable to evaluate tumor response and biologic factors in vivo.

Pharmacokinetics of intravenous alendronate.

Alendronate is a potent bisphosphonate that has been studied for the treatment of osteoporosis and Paget's disease of the bone. To examine the pharmacokinetics of this drug, several groups of postmenopausal women were dosed intravenously in several studies. Twelve patients with metastatic bone disease were administered an intravenous dose of 10 mg of 14C-labeled alendronate (approximately 26 muCi), and plasma, feces, and urine samples were collected for 72 hours. Radioactivity was excreted almost exclusively in urine, and all of it was accounted for by alendronate. Overall recovery accounted for 47% of dose, with the remainder presumed to be retained in bone. Metabolism of alendronate was not observed. Renal clearance of alendronate was 71 mL/min. An additional 10 subjects were given repeated i.v. administrations of alendronate to demonstrate that previous exposure does not alter the pharmacokinetic behavior of the drug. Examination of the findings from these and other studies in which alendronate was administered intravenously revealed that disposition of single doses is linear in the range of 0.125 to 10 mg. With the possible exception of a somewhat greater skeletal retention of a systemically administered dose, the pharmacokinetics of i.v. alendronate were found to be similar to those of other bisphosphonates.

Optimal combination therapy with Navoban (tropisetron) in patients with incomplete control of chemotherapy-induced nausea and vomiting. The Belgian Navoban Group.

Even with the availability of potent and selective serotonin antagonists, chemotherapy-induced nausea and vomiting remain a major problem for many patients. This study aims to evaluate the benefit of combination therapy based on Navoban (tropisetron) in patients who had incomplete control of nausea and/or vomiting induced by chemotherapy when using Navoban as a single antiemetic agent. In their first chemotherapy course, 1072 patients planned to receive at least two identical cycles of emetogenic chemotherapy were treated with 5 mg Navoban once daily. To evaluate three treatments additional to the recommended 5 mg once-daily Navoban regimen during Course 2 in those patients who had shown incomplete control of nausea and/or vomiting on any day of Course 1, a 2 x 2 x 2 factorial design was employed. Of these patients, 445 were centrally randomised to receive an additional dose of open-label dexamethasone (Day 1, 0.2 mg/kg i.v.; Days 2-6, 8 mg p.o.) and/or open-label alizapride (Day 1, 100 mg i.v. and 4 x 50 mg p.o.; Days 2-6, 4 x 5 mg p.o.) and/or double-blind Navoban--that is, doubling the dose to 10 mg once daily or placebo. Complete response rates during Course 1 (CRR, no nausea and no vomiting) were, for Day 1, 72% and for Days 1-6, 48%. More complete responders were observed when dexamethasone was added during Course 2, both on Day 1 (76% vs. 66%, p = 0.020) and on Days 1-6 (50% vs. 34%, p = 0.0004).(ABSTRACT TRUNCATED AT 250 WORDS)

Dose-finding study of tropisetron in cisplatin-induced nausea and vomiting.

BACKGROUND: The purpose of these two studies was to define the optimal therapeutic dose of the 5-HT3 receptor antagonist tropisetron (Navoban, ICS 205-930) in cisplatin-induced nausea and vomiting. PATIENTS AND METHODS: In two multicentre, dose-finding studies of tropisetron in the prevention of cisplatin-induced emesis, cancer patients naïve to chemotherapy or who had not vomited previously were randomly assigned to tropisetron 5, 10, 20 or 40 mg (study I, 143 patients) or 2 or 5 mg (study II, 74 patients), administered as a single intravenous dose over 15 minutes just before the start of chemotherapy. RESULTS: In study I total control of acute symptoms (no nausea and no vomiting) was achieved in, respectively, 66%, 50%, 64% and 50% in the 5-, 10-, 20- and 40-mg groups of patients. A total absence of vomiting alone was seen in, respectively, 71%, 51%, 61% or 58% of patients. None of the differences were statistically significant. In study II there was total acute control in 57% of patients in the 2-mg group and 63% in the 5-mg group (p = NS). Total or major control of vomiting (< or = 2 emetic episodes) was the primary endpoint in study II and was seen in 68% of patients for the 2-mg and 86% for the 5-mg group (p = 0.055). In this study failures ( > 3 vomiting) were rescued with a second infusion of tropisetron (5-mg fixed dose). Three of 8 rescue infusions administered in the 2-mg group prevented further vomiting whereas none of 5 were successful in the 5-mg group during course 1 of chemotherapy. The most frequently reported adverse effects (over all three courses) were headache (6.0% of 217 patients) hypertension (3.7%) and diarrhoea (2.8%). None of the 25 deaths which occurred during the two studies were attributable to tropisetron. CONCLUSIONS: Thus, a single dose of tropisetron provides 24-hour protection against cisplatin-induced nausea and vomiting and is well tolerated. These studies do not allow a firm conclusion but suggest that 2 mg may be subtherapeutic and that 5 mg is as effective as higher doses.

Phase I trial of erbulozole (R55104).

Erbulozole (R55 104) is a water soluble congener of the microtubule inhibitor tubulozole, which has proven to possess anti-invasive, antitumoral and radiosensitizing capacities. A dose-finding study was performed on respectively 9 patients (every three weeks; doses ranging from 20 mg/m2 to 100 mg/m2; maximum 2 cycles per patient) and 6 patients (weekly; doses ranging from 20 mg/m2 to 50 mg/m2; maximum 60 cycles per patient). At all dosages, hematological and biochemical toxicity was very limited. Seven patients complained of pain at the tumor site (grade I to III). Dose limiting toxicity appeared at respectively 100 mg/m2 (one administration every three weeks) and 50 mg/m2 (weekly administration). At this level, 2 patients displayed a dose-limiting Wernicke's encephalopathy-like syndrome. Other secondary effects were headache, fever, exacerbation of dyspnea and moderate nausea and vomiting.

Reversible cardiopathy after accidental overdose of mitoxantrone.

Mitoxantrone is an anthraquinone structurally related to the anthracycline drugs doxorubicin and daunorubicin. In animal tumor models, it was equally cytotoxic as but less cardiotoxic than the parent compounds. We here describe the clinical course of a 9-year old girl who inadvertently received 100 mg/m2 of mitoxantrone as a bolus injection. Hemoperfusion carried out twice with the objective of increasing the drug clearance was totally inefficient. Severe but transient myelotoxicity was induced. Sequential echocardiograms demonstrated a reversible decrease of the shortening fraction of the left ventricle.

Determination of vinca alkaloids in mouse tissues by high-performance liquid chromatography.

A high-performance liquid chromatographic method is described for the determination of vinblastine in various normal mouse tissues, such as lung, heart, liver, kidney and muscles, and in implanted MO4 tumours. Vincristine was used as the internal standard. Freshly obtained mouse tissue or tumour tissue was frozen at -20 degrees C and then lyophilized. After lyophilisation, the dry tissues were pulverized and homogeneously mixed, and an aliquot was suspended in 0.1 M hydrochloric acid. The drugs of interest were then isolated from this suspension using ion-pair extraction at pH 3 with octylsulphate as counter-ion. The obtained extracts were analysed on a reversed-phase system with a cyanopropyl stationary phase. The detection limit was 1 ng/l in plasma and 10 ng/g in tissue. The extraction recoveries of vincristine and vinblastine were between 45 and 67%, and there were no interferences from blank components. Preliminary pharmacokinetic data for different mouse tissues and tumour implanted in muscle tissue are presented.

High-performance liquid chromatographic determination of navelbine in MO4 mouse fibrosarcoma cells and biological fluids.

A high-performance liquid chromatographic method is described for separating and determining navelbine and possible metabolites in plasma, cell culture medium and MO4 cells. Navelbine is extracted from these fluids by ion-pair extraction with sodium octylsulphate as the counter-ion at pH 3. The system uses a cyano column as the stationary phase and a mobile phase of acetonitrile-0.12 M phosphate buffer (pH 3) (60:40, v/v). Application of the method to a study of the pharmacokinetic behaviour of navelbine in MO4 mouse fibrosarcoma cells is reported.

Increasing peak levels of vinblastine given in repeated divided doses.

Pharmacokinetics of vinblastine were assayed in 9 patients, using a high pressure liquid chromatography method. Patients were treated in three different ways: the first 3 patients received bolus injections of vinblastine at a fixed dose of 2 mg/day for 5 consecutive days. Three other patients were treated with 3 mg/m2 vinblastine as a bolus injection on day 1, day 3 and day 8. The remaining 3 patients received a bolus injection of vinblastine of 6 mg/m2 on day 1, day 8 and 15. Blood samples were taken on days 1, 3 and 5 for the first group and on every treatment day for the other groups. The early phase peak levels obtained during the 5 day-treatment increased progressively during repeated treatments, probably due to decreased central compartment volumes and not to drug accumulation. There was no relation between vinblastine levels and orosomucoid levels. The rise in peak level was less predictable during the other methods of treatment (once or twice weekly). This observation calls attention to the necessity of performing drug level monitoring at very early time points, as increasing peak levels during repeated administration may explain unexpected toxicities.

Cellular pharmacokinetics of vinblastine and other vinca alkaloids in MO4 cells.

Accumulation of vinblastine has been studied in different types of cancer cells. We measured the intracellular concentration of vinblastine in MO4 cells and compared it to its extracellular concentration in culture medium. We observed that the ratio of accumulation, expressed as the ratio of intracellular over extracellular vinblastine, was dose-dependent. An initial accumulation level was reached within 30 min and a second dose-induced level after 48 hours. This remained constant for another 5 days. Intracellular accumulation was also seen for vincristine and vindesine but here the phenomenon was less dose-dependent and the maximum level was reached after 6 hours. The accumulation ratio of a single vinca alkaloid in MO4 cells is not different from combined simultaneous exposure with 2 or 3 of the drugs. Energy blocking by sodium azide resulted in an inhibition of the supplementary but not the initial level of vinblastine accumulation. After washing out the medium for vinblastine the intracellular concentration remained about 60 micrograms/ml for 1 microgram/ml vinblastine added to the medium. Based on these results, it is concluded that the accumulation of vinblastine is only partially based on an energy mediated mechanism, in which binding of the drug to at least two types of sites may play an important role.

Treatment of malignant pericardial tamponade with sclerosis induced by instillation of bleomycin.

Five patients with pericardial tamponade of neoplastic origin were treated by pericardiocentesis, drainage and local instillation of bleomycin. The pericardial effusion was adequately controlled in all patients. Survival was influenced not by the pericardial involvement, but by the natural evolution of the tumour. Side effects were minimal. The technique of drainage and bleomycin sclerosis is simple, safe, effective and inexpensive for the management of a malignant pericardial tamponade, providing all precautions necessary for diagnosis and pericardiocentesis are adequately taken.

Pharmacokinetics of mitoxantrone in humans following single-agent infusion or intra-arterial injection therapy or combined-agent infusion therapy.

This study describes the pharmacokinetics of mitoxantrone determined by a sensitive and specific HPLC-method. The time-concentration curves of i.v.-treated patients (15 mg/m2 over 30 min) correspond to a three-compartment model with a T1/2 alpha of 12 min, a T1/2 beta of 93 min, and a slow elimination phase of 36 h. The central compartment volume was 26.22 and the distribution volume, 1381.9. The mean urinary excretion was 4.9% of the total dose. The pharmacokinetic parameters were also defined in five patients who were treated with combination chemotherapy (mitoxantrone 12 mg/m2, methotrexate 30 mg/m2 and vincristine 2 mg). These results were not different from those with the single-drug treatment, except for the volume of the central compartment, which was significantly decreased. The peak levels after hepatic arterial infusion of mitoxantrone were three times lower than those after the identical dose given i.v. to the same patient. Pleural fluid sampling showed a six-fold increase compared with the plasma level (12 ng/ml versus 2 ng/ml). A multiple linear regression analysis of the data revealed correlations between the pharmacokinetic results and some of the baseline parameters. It is possible to predict changes in the kinetic behaviour of mitoxantrone on the basis of these relations but on the other hand toxicity is less predictable from the baseline parameters or from the pharmacokinetic results.

High-performance liquid chromatographic determination of vinca-alkaloids in plasma and urine.

A liquid chromatographic method is described for separating and determining vinblastine, vincristine and vindesine in plasma and urine. The drugs are extracted from the biological material using an ion-pair extraction, with sodium octylsulphate as counter-ion at pH 3. The extracts are injected on a reversed-phase system with a cyano column as stationary phase and a mobile phase composed of acetonitrile-phosphate buffer, pH 3 (65:35, vol. %). Stability studies are carried out for stock solutions of the drugs in water at different temperatures and pH values. The stability of these compounds in plasma is also investigated in the presence of an antioxidant. The method is applied to determine drug levels of vindesine and vinblastine in preliminary pharmacokinetic studies, using vincristine as the internal standard.

Ion-paired high-performance liquid chromatographic determination of mitoxantrone in physiological fluids.

Mitoxantrone is one of the newer anthracenedione derivatives which has already been studied in phase I and II trials, where it has shown significant antitumor activity against a variety of human tumours. To determine the prolonged terminal half-life of mitoxantrone, we developed a sensitive high-performance liquid chromatographic method, providing a detection limit of 1 ng/ml of extracted serum. This system uses a C18 reversed-phase column. The mobile phase consists of a mixture of acetonitrile (30%, v/v) and an ammonium formate buffer (70%, v/v) with a pH of 2.7. Hexane sulphonic acid is added as an ion-pair former. Detection at a wavelength of 658 nm provides a highly selective system, showing no interfering peaks. Ametantrone, another anthracenedione derivative, is used as an internal standard. The extraction procedure for serum also uses hexane sulphonic acid in an ion-paired system. Because of the highly selective detection wavelength, urine samples can be injected without a sample clean-up procedure. This very sensitive method, combined with high selectivity and a fast and inexpensive serum clean-up procedure, has allowed us to document the prolonged terminal plasma half-life of mitoxantrone (levels of 2-5 ng/ml of plasma can still be detected six days after an intravenous infusion of 15 mg/m2 over 30 min). In urine an as yet unidentified metabolite was discovered.